SHOULDER ARTHROSCOPY Setup, Positioning And Portals DR SAMEER ASHAR ASSISTANT PROFESSOR ORTHOPAEDICS DEPARTMENT G.G.GOVT.HOSPITAL JAMNAGAR INDIA
SHOULDER ARTHROSCOPYSetup, Positioning And Portals
DR SAMEER ASHARASSISTANT PROFESSORORTHOPAEDICS DEPARTMENTG.G.GOVT.HOSPITAL JAMNAGARINDIA
HISTORICAL DEVELOPMENTS
• AS EARLY AS 1931, THE AMERICAN
SURGEON MICHAEL BURMAN EXAMINED 25 SHOULDER JOINTS IN CADAVERS WITH AN ARTHROSCOPE
• INITIALY -DIAGNOSTIC ONLY NOW - WELL ESTABLISED
THERAPEUTIC ROLE ALSO
INDICATIONS
• ROTATOR CUFF LESIONS
• SHOULDER INSTABILITIES
• LABRAL LESIONS
• LIMITATIONS OF MOTION
• BICEPS TENDON
• SUB ACROMIAN IMPINGEMENT
• AC JOINT PAIN
• INFECTION
• LOCKING
• LOOSE BODY
• CHRONIC PAIN
INSTRUMENTS
INSTRUMENTS
INSTRUMENTS
source- Arthrex website educational material; images are used just for educational purposes
OPERATING ROOM
FLUID
POSITIONING
• ADVANTAGES • FREE ACCESS TO THE SCAPULA• CONTROLLED AMOUNT OF ARM TRACTION• FACILITATES GLENO HUMERAL SURGERY
• DISADVANTAGES• NEED FOR TRACTION DEVICE (ARM HOLDER)• TIME CONSUMING• GREATER RISK OF POSITION-RELATED INJURIES• COMPLEX PADDING• COMPLEX DRAPING• DIFFICULT CONVERSION TO AN OPEN
PROCEDURE
POSITIONING• ADVANTAGES
• ALLOWS FOR RAPID CONVERSION TO AN OPEN PROCEDURE
• NORMAL VERTICAL ORIENTATION OF SHOULDER ANATOMY
• WELL SUITED FOR SUB-ACROMIAL PROCEDURES
• LOWER COST
• SAVES TIME
• FACILITATES DRAPING
• DISADVANTAGES• DIFFICULT OR POOR VISUALIZATION OF THE
MEDIAL SCAPULAR MARGIN
• RISK OF HYPOTENSION
CONTROL OF BLEEDING
Arthroscopic pump• Constant flow is maintained and pressure OF 60-70 MM HG
• Chances of extravasation and increase compartment pressure is high
• Be aware of the system you use regarding pressure mechanisms
1 ml of 1;1000 epinephrine in each 3000 ml bag of irrigation fluid if not contraindicated
Most effective method is hypotensive anaesthesia
PORTALS
SOME COMMON PORTALS-POSTERIOR
• POSTERIOR PORTAL • primary viewing portal used for diagnostic
arthroscopy
• LOCATION AND TECHNIQUE• located 2 cm inferior and 1 cm medial to
posterolateral corner of acromion
• portal may pass between infraspinatus (suprascapular nerve) and teres minor (axillary nerve) or pass through the substance of infraspinatus
• this is usually the first portal placed
• direct anteriorly towards tip of coracoid
SOME COMMON PORTALS-ANTERIOR
• ANTERIOR PORTAL
• function• viewing and subacromial decompression
• LOCATION & TECHNIQUE• lateral to coracoid process and anterior to AC joint• portal passes between rotator interval• Inside out or outside in
• THIS PORTAL IS USUALLY PLACED UNDER DIRECT SUPERVISION FROM THE POSTERIOR PORTAL WITH AID OF SPINAL NEEDLE
SOME COMMON PORTALS-LATERAL
• LATERAL PORTAL• FUNCTION
• SUBACROMIAL DECOMPRESSION
• LOCATION & TECHNIQUE
• LOCATED 1-2 CM DISTAL TO LATERAL EDGE OF ACROMIUM
• PORTAL PASSES THROUGH DELTOID (AXILLARY NERVE)
SOME COMMON PORTALS-SUPERIOR
• The superior portal (Neviaser portal, supraspinatus portal) is placed approximately 1 em medial to the acromion between the clavicle and scapular spine and is used for instrumentation or inflow.
• STRUCTURES AT RISK
• suprascapular nerve and suprascapular artery, located about 2 mm medial to this portal.
OTHER PORTALS
• Anterior superior portal. This portal is established just anterior to the biceps tendon.• Anterior inferior portal.
This portal is placed just proximal to the subscapularis tendon.Structures at risk from the anterior portals are- The cephalic vein and The musculocutaneousnerve.
• Posterior subacromial portal
• Anterior subacromial portal
COMPLICATIONS
POSITION AND DISTRACTION
• Lateral- pressure injury to ulnar nerve in arm and peroneal nerve in leg
• Beach chair-hypotension and CVA
• Traction- more than 8 kg of weight and more
than 450 of abduction can cause nerve palsy
PORTAL RELATED
• Cartilage lesions
• Nerve lesions
• Axilary- too posterior portal
• Supra scapular-too medial portal
• Musculo-cutaneous- keep anterior portals lateral to coracoid
TECHNIQUE RELATED
• Cuff tear
• Glenoid injury
• Acromian fracture
• Hardware breakage
• Infection
• Post operative haemarthrosis
DOCUMENTATION
• Must for any arthroscopic procedure
• Includes video recording and still images
• Images are powerful tool than description
• Pre and post procedure images are better for comparison.
SOME PIONEERS IN SHOULDER SURGERY
THANK YOU